Options are slim
 

Hey everyone, I saw my ortho spine surgeon yesterday for the third time in about a year. This was a pre-op appt. for my fusion surgery I have scheduled for late September. We also discussed the possibility of ADR for my L2-3 ruptured disc. He said even "if" it were an option for me in the U.S., which it is not, that he wouldn't recommend ADR for my lumbar. Part being that I have a 3 level fusion below it and partly because he feels that cervical ADR is a wonderful option for patients but doesn't have the same enthusiasm for lumbar ADR. He feels that there are too many other "obstacles" to consider when it comes to ADR being a success in the lumbar region, and he has read of too many failures of ADR in lumbar region and says that is partly why insurance won't cover it. Now as far as my making an international trip to have ADR done for my cervical problems, he offered to do all the pre-op work-ups here for me. He wished that he could do the same procedures here in the US and he would definitely use ADR in my cervical. But he didn't hesitate at the idea of my going over there to do a procedure that ultimately would be taking money out of his pocket.

you certainly do have a unique situation in your lumbar region... i highly doubt any US surgeon would tackle that since you have fusions below AND L2/3 is a tricky level on which to operate. you also may not have much to gain from an ADR that high, but unfortunately there's zero data on that since you're likely an N of 1.

i saw you tried to PM me, send me an email, see below...

You appear to have more confidence in your path forward and that is good.


slackwater_sf

Side Notes,
I do not recall seeing a journal article or case report with ADR at L2/L3.

Other:
Your surgeon said something about lumbar obstacles / failures. In the event somebody reads this and wants a little context, see the below.

Lumbar ADR and Fusion at multiple levels have "obstacles"(?), let's say points and counter-points measured over time periods. The points measured are outcome (ODI/VAS, quality of life), complications, durability and re-operation.

Insurance companies have a lot of Fusion and some ADR/TDR data points. Insurance companies ~understand lumbar fusion points and what costs money. The data around lumbar ADR / TDR is not complete. Patients, surgeons, medical community, etc, want a new surgical (or other) technique, a grand slam, out of the park, significant statistical improvement, etc. for patients. ADR/TDR has OK+ metrics, needing OK+++.

The surgeon noted too many failures with Lumbar ADR. I suggest the complication and reoperation rate between Fusions and ADR need has been measured for single-level operations and the outcomes are published for the limited data set of xx years. This goes back to a more significant statistical difference, or "need a grand slam".

The multi-level (2 or 3 level) operations with Fusion and ADR have slightly lesser outcomes than single-level. Two (2) Level ProDisc results measured OK+ compared to Fusion (note.Level.J.Bone.Joint.Surgery.2-Level)

The biomechanics of a three-level Lumbar ADR / TDR has risk factors. Please note the below to make the fusion choice correct (note. E.Spine.J.2012)
Effect of multilevel lumbar disc arthroplasty on [lumbar] spine kinematics and facet joint loads in flexion and extension: a finite element analysis.
Schmidt H, Galbusera F, Rohlmann A, Zander T, Wilke HJ
Eur Spine J. 2012 Jun;21 Suppl 5:663-74.
(1) the more artificial discs are implanted, the stronger the increases in spinal mobility and facet joint forces in flexion and extension;
(2) deviations from the optimal implant position lead to strong instabilities.

The European Spine Journal article notes device "lift-off" is possible with three levels and the use of Charite'. The "position" of the ADR increases in importance with more levels. The journal reports from the above, other surgeons and ortho-biomechanial researchers note lumbar ADR surgical placement will affect the surgical success rate.


Cervical ADR is getting to be more accepted (note.J.Neursurgery.Spine)

Slackwater, thank-you for the research assistance and the help with understanding my case more clearly. I appreciate your help, D